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CHICAGO – A recurring diagnosis, a recurring code, and recording omissions are among the top triggers for chart reviews, according to Dr. Howard Wooding Rogers, a Norwich, Conn., dermatologist who conducts chart reviews for private insurers.
Chart reviews by the Medicare Recovery Audit Contractor (RAC) program strike the most fear in physicians’ hearts, but chart reviews are "coming from all directions" – including private insurers, Medicare Advantage plans, and even patients themselves – and they’re becoming more common, Dr. Rogers said at the American Academy of Dermatology summer meeting.
Billing patterns that fall outside the patterns of specialty peers – employing one treatment modality at a higher intensity, treating predominantly one diagnosis, and using only one intervention – can trigger a chart review. So can performing multiple procedures during one visit, recurring procedures in one patient, and elevated use of one procedure code.
Patient complaints and medical record requests also can factor into the mix. "I’m a Mohs surgeon, and when I’m working, frequently patients are uploading their surgical photos in real time to Facebook. At that point, there are potentially 1,000 people out there to help code that [procedure] for the patient. If your code and their code don’t match up, the patient could easily call the insurer and send that selfie," he said.
Complex closures are on insurers’ radar, Dr. Rogers added. "Just last month, I helped [a doctor] defend against a review in which 20 complex closure payments were taken back. The reality was he wasn’t documenting sufficiently [the] extensive undermining [that was required] and he wasn’t documenting medical necessity." Current Procedural Terminology (CPT) states that complex closures are repairs that require more than a layer of closure such as scar revision, extensive undermining, or retention sutures.
Knowing the correct primary and secondary codes for procedures can speed payment and reduce billing scrutiny, Dr. Rogers said. The AAD offers a variety of products for improving coding accuracy.
Failing to include a secondary code when performing medically necessary removal of benign skin lesions often results in Medicare payment denials. Medicare considers lesions to be cosmetic if they do not pose a threat to health or function and the billings include only a primary code. The secondary code informs Medicare when lesions are symptomatic, restricting function of a body orifice, spreading rapidly, or possibly malignant, he pointed out.
"Remember, the one best chance to get paid for what you do is to bill it right the first time," Dr. Rogers noted.
On Twitter @legal_med
CHICAGO – A recurring diagnosis, a recurring code, and recording omissions are among the top triggers for chart reviews, according to Dr. Howard Wooding Rogers, a Norwich, Conn., dermatologist who conducts chart reviews for private insurers.
Chart reviews by the Medicare Recovery Audit Contractor (RAC) program strike the most fear in physicians’ hearts, but chart reviews are "coming from all directions" – including private insurers, Medicare Advantage plans, and even patients themselves – and they’re becoming more common, Dr. Rogers said at the American Academy of Dermatology summer meeting.
Billing patterns that fall outside the patterns of specialty peers – employing one treatment modality at a higher intensity, treating predominantly one diagnosis, and using only one intervention – can trigger a chart review. So can performing multiple procedures during one visit, recurring procedures in one patient, and elevated use of one procedure code.
Patient complaints and medical record requests also can factor into the mix. "I’m a Mohs surgeon, and when I’m working, frequently patients are uploading their surgical photos in real time to Facebook. At that point, there are potentially 1,000 people out there to help code that [procedure] for the patient. If your code and their code don’t match up, the patient could easily call the insurer and send that selfie," he said.
Complex closures are on insurers’ radar, Dr. Rogers added. "Just last month, I helped [a doctor] defend against a review in which 20 complex closure payments were taken back. The reality was he wasn’t documenting sufficiently [the] extensive undermining [that was required] and he wasn’t documenting medical necessity." Current Procedural Terminology (CPT) states that complex closures are repairs that require more than a layer of closure such as scar revision, extensive undermining, or retention sutures.
Knowing the correct primary and secondary codes for procedures can speed payment and reduce billing scrutiny, Dr. Rogers said. The AAD offers a variety of products for improving coding accuracy.
Failing to include a secondary code when performing medically necessary removal of benign skin lesions often results in Medicare payment denials. Medicare considers lesions to be cosmetic if they do not pose a threat to health or function and the billings include only a primary code. The secondary code informs Medicare when lesions are symptomatic, restricting function of a body orifice, spreading rapidly, or possibly malignant, he pointed out.
"Remember, the one best chance to get paid for what you do is to bill it right the first time," Dr. Rogers noted.
On Twitter @legal_med
CHICAGO – A recurring diagnosis, a recurring code, and recording omissions are among the top triggers for chart reviews, according to Dr. Howard Wooding Rogers, a Norwich, Conn., dermatologist who conducts chart reviews for private insurers.
Chart reviews by the Medicare Recovery Audit Contractor (RAC) program strike the most fear in physicians’ hearts, but chart reviews are "coming from all directions" – including private insurers, Medicare Advantage plans, and even patients themselves – and they’re becoming more common, Dr. Rogers said at the American Academy of Dermatology summer meeting.
Billing patterns that fall outside the patterns of specialty peers – employing one treatment modality at a higher intensity, treating predominantly one diagnosis, and using only one intervention – can trigger a chart review. So can performing multiple procedures during one visit, recurring procedures in one patient, and elevated use of one procedure code.
Patient complaints and medical record requests also can factor into the mix. "I’m a Mohs surgeon, and when I’m working, frequently patients are uploading their surgical photos in real time to Facebook. At that point, there are potentially 1,000 people out there to help code that [procedure] for the patient. If your code and their code don’t match up, the patient could easily call the insurer and send that selfie," he said.
Complex closures are on insurers’ radar, Dr. Rogers added. "Just last month, I helped [a doctor] defend against a review in which 20 complex closure payments were taken back. The reality was he wasn’t documenting sufficiently [the] extensive undermining [that was required] and he wasn’t documenting medical necessity." Current Procedural Terminology (CPT) states that complex closures are repairs that require more than a layer of closure such as scar revision, extensive undermining, or retention sutures.
Knowing the correct primary and secondary codes for procedures can speed payment and reduce billing scrutiny, Dr. Rogers said. The AAD offers a variety of products for improving coding accuracy.
Failing to include a secondary code when performing medically necessary removal of benign skin lesions often results in Medicare payment denials. Medicare considers lesions to be cosmetic if they do not pose a threat to health or function and the billings include only a primary code. The secondary code informs Medicare when lesions are symptomatic, restricting function of a body orifice, spreading rapidly, or possibly malignant, he pointed out.
"Remember, the one best chance to get paid for what you do is to bill it right the first time," Dr. Rogers noted.
On Twitter @legal_med
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2014
